Agnes Jonsson is a graduate of University College Dublin in 2013 and is currently working as a Registrar in Orthogeriatrics in St. Vincent’s Hospital in Dublin. Her areas of interest are dementia care and quality improvement. She wrote this blog with input from Dr. Yasser Aljabi, Orthopaedic Registrar. Together they are working to create a pathway of care for vertebral fractures in St. Vincent’s Hospital.
Osteoporotic fragility fractures have an estimated annual cost of 2 billion pounds in the UK. This includes the cost of acute hospital stay, rehabilitation and social care. Only a very small proportion of the cost is invested in pharmacological management and secondary prevention of osteoporosis. The National Osteoporosis Foundation recommends treatment with antiresorptive agents for patients with confirmed osteoporosis on DXA and for patients with neck of femur or vertebral fractures. Vertebral compression fractures have recently started to attract increasing amounts of attention, similar to that shown for hip fractures years ago prior to the implementation of hip fracture pathways of care.
Previous blogs have discussed the value and the difficulties in creating a pathway for symptomatic compression fractures that necessitate hospital admission. The difficulty lies in sparse and conflicting evidence on the best treatment of this acutely painful condition. While I agree this is a worthwhile pursuit, we must not overlook those silent fractures for which we do have the evidence. And the evidence shows clearly that vertebral fractures are a warning sign not to be ignored. A patient with a vertebral fracture has a 19% risk of further fracture in the next year. In fact, a previous fracture is the strongest predictor of future fracture risk, and despite this, only around 30% of patients with vertebral fractures receive bone protection. Retrospective studies have shown a rate of previous vertebral fracture in 14% of patients admitted with hip fractures, many of which were undiagnosed and without secondary prevention. Recently the Danish cross-sectional observational study of hip fractures predicted that 1 in 6 hip fractures could be prevented based on the presence of previous major osteoporotic fracture.
While hip fractures are usually multifactorial, and a reflection of falls risk, frailty as well as bone health, vertebral compression fractures ordinarily occur earlier in the natural course of osteoporosis. One would think this provides an optimal opportunity to assess bone health and instigate secondary prevention. Regrettably this is not the case. Vertebral fractures are under-diagnosed and under-treated. Not infrequently they go unmentioned in radiological reports, or when incidentally found we are too focused on the acute problem necessitating imaging, that we fail to recognise this herald of future gloom.
It is welcomed and overdue that vertebral fractures are starting to gain momentum and attention. The potential and need for streamlining inpatient management of acutely painful fractures is undeniable. But if establishing a pathway for this purpose, it would be foolish to ignore the warning sign that is the less severe or asymptomatic fracture, which is a massively underutilised clinical and radiological finding when it comes to diagnosing osteoporosis.
I believe the key lies in recognising osteoporosis as a chronic condition requiring active medical management. Its asymptomatic nature (until the time of fracture!) and the side effects of medications make it difficult for patients to value the need for treatment. It is time we recognise how poorly we are doing in secondary prevention of fractures and establish coordinated specialist services to provide this care, and to communicate recommendations with GPs. I believe geriatricians are best suited to provide these services as ideally, a falls assessment can occur in tandem which would provide a holistic approach to the benefit vs risk of treatment. With the numbers of fragility fractures predicted to double by 2030 prevention urgently needs to be addressed.
An Excellent Article.